Healthcare Provider Details

I. General information

NPI: 1962965038
Provider Name (Legal Business Name): KELA MICHELE BERGREN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2019
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 S COUNTRY CLUB RD STE 130
TUCSON AZ
85714-2203
US

IV. Provider business mailing address

3950 S COUNTRY CLUB RD STE 130
TUCSON AZ
85714-2203
US

V. Phone/Fax

Practice location:
  • Phone: 520-874-4800
  • Fax:
Mailing address:
  • Phone: 520-874-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0069342
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR77265
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: